Improvement Should Not Be Required for
Medicare Coverage of Skilled Therapy

 

The Centers for Medicare & Medicaid Services (CMS) has incorrectly denied coverage for skilled nursing facility (SNF) and home health care to individuals, according to two recent federal court decisions. CMS had denied coverage because, in the Medicare program’s view, the plaintiffs’ conditions had not improved. The courts found, however, that under the law, individuals could obtain coverage for qualified therapy in SNF and home care settings if the services were needed to prevent deterioration of their condition, and that improvement is not required for coverage of such services. The Center for Medicare Advocacy (CMA) is leading an education and advocacy campaign about the improper use of the improvement standard in Medicare. The focus of the campaign is to raise awareness about the issue, and to eliminate the improper use of the standard by Medicare and Medicare contractors.

The Obama administration has so far been unwilling to correct its guidelines, so beneficiaries denied coverage have had to resort to the courts. "Beneficiaries are frequently told that Medicare will not cover skilled services if their underlying condition will not improve," a group of 17 House Democrats wrote in a letter to the Obama administration requesting that it change its policies. "For example, as people with multiple sclerosis are often not likely to improve, skilled services such as physical, occupational and speech therapies that are necessary to slow the progression of the disease, or maintain current function, are denied. As a result, these individuals conditions deteriorate --frequently leading to more intense, more expensive services, hospital or nursing home care."

However, because the court opinions apply only to their districts, lawsuits will likely continue unless/until the Obama administration instructs its contractors to follow the law.

CMS also released this week the final rule on prospective payments for home health care in 2011, which includes regulations implementing coverage for skilled therapy services in a home health care setting. Some stakeholders who had earlier provided comments on the proposed rule, including CMA and the Medicare Rights Center, had expressed concern about the clarity of CMS’s current coverage requirements, and cautioned that regulatory language improperly emphasized improvement as a requirement for coverage. CMS provided a response to comments, stating that the new rule neither limits nor expands available coverage, and that maintenance therapy may be covered, as it always has been, if the condition of the patient requires complex services that only a qualified therapist can provide.

-Adapted from “Improvement Not Required for Coverage of Skilled Therapy”, Medicare Watch, Medicare Rights Center, November 04, 2010 and ElderLaw News from ElderLawAnswers, November 12, 2010, http://www.elderlawanswers.com/resources/article.asp?id=8738&Section=4, retrieved 11/12/10.

 

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